Form 720CD Application for Lump-Sum Payment

	Application for Lump-Sum Payment		PBGC Form 720CD
Pension Benefit Guaranty Corporation. P.O. Box 151750, Alexandria, Virginia 22315-1750		For assistance, call 1-800-400-7242

	Plan Name: FX.PrismCase.CaseTitle.XF
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF
	Date Printed: 01/12/2021
	Date of Plan Termination: FX.PrismCase.DOPT.XF

INSTRUCTIONS: Use this form to request a lump-sum payment if you are a child or dependant pursuant to a Qualified Domestic Relations Order (QDRO). When "proof required" is indicated, please enclose a copy of a birth or baptism certificate, or a U.S. Passport, whichever is appropriate, unless you already sent PBGC a copy of this document. If you have questions about other acceptable documents, call our Customer Contact Center at 1-800-400-7242. Please print clearly with dark ink.

1. General information about you

Last Name

First Name

Middle Name

Other Last Name(s) Used

Social Security Number

Date of Birth (PROOF REQUIRED)

Gender

male



-

-

/

/

female



Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Province

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

_{Name of plan participant:}

2. Signature – Sign and date this application. Knowingly and willfully making false, fictitious or fraudulent statements to the Pension Benefit Guaranty Corporation is a crime punishable under Title 18, Section 1001, United States Code.

I declare under penalty of perjury that all of the information I have provided on this form is true and correct.
signature		date

Approved OMB 1212-0055

Expires 12/31/15